2. To Bundle or Not to Bundle? Ronald Barkley, CCBD Group Mark Krasna, MD, Meridian Cancer Care Constantine Mantz, MD, 21 st Century Oncology Joseph O’Hara, Horizon Blue Cross Lee Newcomer, MD, United Healthcare Mark Sobczak, MD, Fox Chase Cancer Center Larry Strieff, MD, Hill Physicians Medical Group

3. A Definition Think of a “bundled price” as a pre-determined payment for furnishing a specific treatment or procedure or for treating a clinically defined episode of care over a specified period of time A bundled rate can be the sole source of payment for rendering a service (prospective bundle) or can be reconciled after rendering the service, typically against a fee-for-service comparison (retrospective bundle)

4. To Bundle or Not to Bundle? Presentation Format Each panelist briefly describes their experience with oncology bundled payment A couple “challenge” questions for panel response Open forum: audience Q&A

5. Constantine Mantz, MD, Chief Medical Officer 21 st Century Oncology Multiple active bundled payment agreements for radiotherapy since 2012 Inclusive of all radiotherapy services for nearly all (98%) cases referred for treatment Goals and outcomes – reduce administrative costs – decouple clinical decision making from reimbursement – permit latitude for physician to exercise full clinical judgment on prescribing a course of care – improve patient satisfaction with insurance product

6. Mark Krasna, MD, Corporate Medical Director Meridian Cancer Care Proposal to develop complete episode of care Bundles for regionally advanced non metastatic Starting w/ lung, breast, colon Include multimodality therapy Adherence to guidelines Outcomes include-timeliness; reduced er/inpt adm Greatest Challenge: Define beginning and end of episode

7. Joseph O’Hara, Director Marketplace Innovations Horizon Blue Cross Blue Shield of NJ Episodes of Care (EOC) Obstetrics, cardiac, orthopedics, gastrointestinal Cancer: adjuvant breast, lung, colon – Tx and Post Tx Total cost of care vs. condition specific encounters Using shared data to stratify patients

8. Mark Sobczak, MD, Chief Network Officer & SVP Fox Chase Cancer Center Kidney cancer surgery

9. Lee Newcomer, MD, MHA, Senior Vice President United Healthcare

10. Larry Strieff, MD, Specialty Medical Director Hematology Oncology Division Chief Hill Physicians Medical Group

11. Oncology Case Rate (OCR) Bundle Payment System: Five Year Program Results Larry Strieff, MD Specialty Medical Director Hematology Oncology Division Chief Hill Physicians Medical Group February 8, 2016 Khanh Nguyen, Pharm.D. Director, Clinical Support Hill Physicians Medical Group PriMed Management Consulting Services, Inc.

12. Hill Physicians Medical Group  Independent Physician Association founded in 1984  Provider network: 3,800 providers and consultants  980 Primary Care  2,260 Specialists ( 170 Oncologists )  Service the Northern California area  300,000 Members  5 Regions - 9 Counties 12

13. Necessary Goals  Respond to financial pressures to moderate the cancer care cost trend  Improve the quality of care  Align our oncologists’ incentives with organization’s initiatives 13

14. The Model Two Linked Modules - Act as Checks & Balances Case Rate Payments Cancer dx are grouped Paid monthly Providers bear some risk Stop loss program protects providers CALCULATED TO BE EQUIVALENT TO 100% FFS 14 Quality Management Program Clinical Quality Patient Experience Utilization OPPORTUNITY FOR ADDITIONAL 10% INCENTIVE

15. Part I: Case Rates Case Rates - Description Case rates have different values for different cancer diagnosis groups  All cancers grouped into diagnosis groupings  in situ excluded  Includes all services provided to patient in MD office except imaging & rad tx Paid monthly  Prospective, once case begins Providers bear some risk  At risk when costs exceed cumulative case rate but not yet at stop-loss Stop loss program protects providers  Providers paid case rates AND reduced FFS after reaching stop loss CALCULATED TO BE EQUIVALENT TO 100% FFS 15

16. Part II - QMP 16 QMP DomainsDescription Clinical Quality  Subset (25 - 30) of ASCO QOPI core measures Patient Experience  CG-CAPHS  Internally developed referring PCP satisfaction survey Utilization  IP bed days  ED visits  Infusion Center Use  Chemo Initiation OPPORTUNITY FOR ADDITIONAL 10% INCENTIVE  These are NEW dollars that previously were not available to the oncologists

17. So, What We Developed & Implemented…. 17 Case Rate = An APM (Alternate Payment Model) Cancer dx are grouped Paid monthly Providers bear some risk Stop loss program protects providers CALCULATED TO BE EQUIVALENT TO 100% FFS QMP = VBP4P (Value Based Pay-for- Performance Program) Clinical Quality Patient Experience Utilization OPPORTUNITY FOR ADDITIONAL 10% INCENTIVE

18. 18 Outpatient Total Oncology PMPM Trend OCR vs. Non-OCR Practices (Control) 18

19. Clinical Quality of Care – OCR Performance 19 ASCO = American Society of Clinical Oncology Adherence to NCCN Guidelines 19  96% pathway adherence based on cancer stage observed in treatment of colon cancer patients 19

20. 20

21. Utilization Measure 21 Inpatient Bed Days OCR: 17% Decrease 2014 vs. 2015 Non- OCR: 1.2% Increase 2014 vs. 2015 21

22. Utilization Measure 22 ED Visits OCR: 33% Decrease 2014 vs. 2015 Non- OCR: 0.4% Increase 2014 vs. 2015 22

23. Did we Achieve Our Goals?  Respond to financial pressures to moderate the cancer care cost trend  OCR practices continue to bend the cost curve over 5+ years of program experience.  Improve the quality of care  OCR practices demonstrated year-over-year improvements in performance on ASCO clinical quality measures.  OCR practices out-performed standard FFS model in key utilization metrics (i.e. Bed Days, ED visits).  Align our oncologists’ incentives with organization’s initiatives 23

24. What Is Next?  Improve our program  Incorporate best practices from other initiatives  Adapt our program to the changing marketplace  Does our program have potential as an oncology APM in the MACRA environment? 24

25. Panel Question 1 The treatment of cancer is constantly evolving with routine introductions of new and costly technology and drugs. How do you account for the costs of new technology and drugs once a bundled price has been established?

26. Panel Question 2 Many Payors have already launched their own versions of oncology alternative payment and none deploy prospective bundled pricing. For example: Anthem Quality Oncology Care, Aetna Oncology Medical Home, CMMI-Oncology Care Model. What, if anything, does this implicate regarding market readiness for bundled pricing? Will bundled pricing in oncology become predominate or is a care management fee + shared savings model preferred for oncology?

27. To Bundle or Not to Bundle? Questions? Thank You for Your Attention Ronald Barkley rbarkley@ccbdgroup.comrbarkley@ccbdgroup.com Mark Krasna, MD MKrasna@meridianhealth.comMKrasna@meridianhealth.com Constantine Mantz, MD Constatine.Mantz@21co.comConstatine.Mantz@21co.com Joseph O’Hara Joseph_O’Hara@horizonblue.com Mark Sobczak, MD Mark.Sobczak@fccc.eduMark.Sobczak@fccc.edu Larry Strieff, MD, Larry.Strieff@hpmg.comLarry.Strieff@hpmg.com